Building more resilient health systems: lessons from the HIV and TB response

It has been a steep learning curve since I joined UNAIDS.

The COVID-19 pandemic exploded just two months into my tenure.  

Global systems were ill-prepared for the devastating impacts of COVID on health, lives, communities and economies.  

COVID-19 reminds us that pandemics cannot be tackled by health systems alone. Far from being just a health crisis, COVID-19 is also a rights crisis, a social crisis, an economic crisis. 

And whilst we fight this new pandemic, we cannot lose sight of our collective goals of Ending AIDS and TB by 2030. COVID-19 may have made our task harder, but this is also a moment to rethink our response to global pandemics and how we guarantee the right to health of all. 

There were 24.5 million people on antiretroviral treatment by mid-2019. Despite this success, less than half of the people with HIV-related TB disease received HIV and TB treatment in 2018. As a result, TB causes one in three AIDS-related deaths–despite being preventable and curable!  

 Without concerted action this will worsen as resources are directed to COVID.  

 We must not repeat the mistakes of the past!  

 From our work on HIV, we know that to beat pandemics, we must focus on addressing inequality in access and inequality in outcomes, head on.  

We need to capitalize on our hard-learned lessons from the AIDS response around the importance of communities, human rights and a multisectoral approach to build ‘systems for health’ that can absorb the current COVID shockwaves and future-proof us against other pandemics.  

I want to share three priority areas in this pivotal moment. 

Essential to all three, and all our work must be the meaningful engagement and partnership with affected civil society from the outset.    

My first priority is rapid and equitable access to COVID innovations. This is non-negotiable! 

When AIDS was discovered almost 40 years ago, tests were scarce and unreliable, there was no treatment, vaccine or other reliable combination prevention. Sound familiar?  

However, people living with HIV, self-empowered by science and grassroots activism, challenged the system that secured monopolies over essential HIV medicines, paving the way to accelerated, equitable and affordable access to priority medical innovations for many diseases since.   

Generic production in countries such as Brazil and India drove the price of ART from $10,000 to less than $100 a year and global HIV treatment coverage accelerated exponentially from less than 1000 people in low-income countries on basic ART in 2000 to 24.5 million people on state-of-the-art treatment by mid-2018.   

Until a few years ago, there had been no new drugs and regimens to prevent and treat TB, and unfortunately many of the new drugs and regimens available today remain unaffordable or inaccessible to people living in low-income countries.  

The poorest must be equal beneficiaries of the innovations arising from billions of dollars invested by governments in COVID research. It is imperative that people come before profits, patents and intellectual property.    

That’s why UNAIDS is co-leading the global campaign for a “People’s Vaccine” to make the COVID-19 vaccine and other technologies patent-free, mass produced, distributed fairly and free at the point of use.  

My second priority is building a truly multisectoral response focused on addressing the broader and intersecting determinants of health.    

COVID, like HIV and TB, thrives on inequality in our societies.  

So we must always put people at the centre of the response through rights based and gender transformative approaches. We must also step up to end stigma and discrimination.  

Can you imagine the multiple layered and additive stigma that a pregnant adolescent girl living with HIV, who has a cough, must overcome today to get the care she needs…? 

This kind of ingrained stigma leads to poorer health outcomes and has no place in our world. 

A recent survey of national COVID response committees showed they are predominantly made up of politicians and biomedical scientists with scant representation of social scientists, COVID survivors or affected and at-risk communities.  

It is little wonder strict public health measures supported by punitive laws are being implemented without creating the enabling environment for the most-a-risk to be able to comply.  

•  How can people living in overcrowded informal settlements physically distance themselves?  
•  How can the poorest access soap and clean water to hand-wash effectively?  

Institutionalizing the role of non-health sectors, including justice, law enforcement, education, private sector and civil society, in addressing the broader determinants of health is central to overcoming HIV, TB and COVID and more broadly achieving the SDGs.  

Thirdly, we need to move away from one-size-fits-all approaches to more effective, sustainable and resilient people-centred approaches driven by data. Granular, real-time disaggregated data are needed. 

Community-led monitoring adds speed and detail in reporting drug-stock outs, human rights violations and stigma and gender assessments.  

The COVID response can expand more rapidly and effectively by harnessing existing infrastructure built through TB and HIV investment —supply chains, data systems, laboratories, trials networks and community infrastructure. 

For example, without the multi-purpose laboratory machines bought for the molecular diagnosis of TB, viral hepatitis, viral load and early infant diagnosis, most low-income countries would have little to no capacity to test for COVID. 

In return, additional COVID investments strengthen them for the greater global good.  

The COVID-19 crisis is a decisive moment for all of us. The right to health has never been higher on the global agenda. This is the time to strengthen the resilience of systems for health and future-proof the health and wellbeing of generations to come. This is how we will overcome this crisis and finally end AIDS and TB.